Provider Enrollment Forms
Note: Please complete all forms in black ink only.
- Applied Behavioral Analyst (pdf, 445kb)
- Durable Medical Equipment (DME) Providers (pdf, 190kb)
- Home Health/Hospice Providers (pdf, 982kb)
- In-state & Out-Of-State Group Providers (pdf, 570kb)
- In-State & Out-Of-State Hospital Providers (pdf, 1,306kb)
- Instate and Out-Of-State Individual Provider Joining A Group (pdf, 796kb)
- In-state & Out-Of-State Provider In Private Practice (pdf, 126kb)
- MCC Choices HCBS Providers (pdf, 484kb)
- MCC Instate and Out of State Individual Provider Joining a Group (pdf, 659kb)
- MCC Instate and Out of State Provider In Private Practice (pdf, 732kb)
- MCC Instate and Out of state Group Provider (pdf, 348kb)
- Non-Emergency Transportation Providers (pdf, 383kb)
Miscellaneous Provider Forms
- Address Change (pdf, 27kb)
- Adjustment/Void Form (pdf, 2,157kb)
- Certification of Medical Necessity for Abortion (English) (pdf, 100kb)
- Certification of Medical Necessity for Abortion (Spanish) (pdf, 425kb)
- Disclosure Form For a Provider Entities (pdf, 8ikb)
- Disclosure Form For a Provider Person (pdf, 69kb)
- Hysterectomy Acknowledgment Form (pdf, 105kb)
- Medicaid Reclamation Claim Provider Refund Request Form (pdf, 34kb)
- Name Change Form For Individual/Sole Proprietor/Group
- National Provider Identification (NPI)
- Provider Participation Agreement (pdf, 94kb)
- Provider Termination Form (pdf, 64kb)
- Remittance Advice Request Form (pdf, 17kb)
- Sterilization Consent Form (pdf, 115kb)
- Substitute W-9 Form (pdf, 9kb)
- TennCare Medicaid Benefits Limited Reassigment Authorization (pdf, 680kb)
- Third Party Liability Update Request Fax Form (pdf, 518kb)
